Citation Nr: 21013153 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 14-99 776A DATE: March 8, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT The Veteran’s PTSD is related to a verified in-service stressor. CONCLUSION OF LAW PTSD was incurred in active service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to January 1970. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision by the Department of Veterans Affairs (VA). A hearing was held before a Decision Review Officer (DRO) of the agency of original jurisdiction (AOJ) in September 2017. A transcript of the hearing is of record. In an October 2018 decision, the Board denied other claims that were on appeal, including the propriety of the severance of service connection for depressive disorder with alcohol abuse, and remanded the above claim for further development. The depressive disorder claim was subject to proceedings before the United States Court of Appeals for Veterans Claims (Court) before being ultimately withdrawn by the Veteran after return of the matter to VA. See 2019 Court documents, June 2020 BVA remand, July 2020 representative written statement, and August 2020 AOJ letter. The case has since been returned to the Board for appellate review. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for PTSD. The Veteran has contended that he developed PTSD as a result of his military service while stationed in the Republic of Vietnam, inasmuch as he feared for his life from witnessing enemy soldiers mutilate and drag a body down the street and receiving incoming enemy sniper fire. He has withdrawn his claim related to a depressive disorder, as noted above. See, e.g., November 2010 VA examination report; February 2013 written statement; September 2017 DRO Hrg. Tr.; November 2020 representative written appellate brief. Regarding the claimed stressor, the Veteran’s service personnel records confirm that he was stationed in Vietnam from January 1969 to January 1970 and served as an oxygen-acetylene production specialist/assistant operator with the 865th Engineering Detachment. He received a certificate of achievement from the United States Army Support Command in Qui Nhon for service in support of Free World Military Forces operations for that assignment. The Veteran also submitted copies of service department materials in support of his claim, including a September 1969 operational report showing that the Qui Nhon area had incidents of enemy activity, including sniper attacks, during the last quarter. The Board finds that the Veteran’s reports as to his recollection of the claimed in-service stressor competent and credible, and the stressor is consistent with the places, types, and circumstances of his service. In addition, the August 2019 VA examiner determined that the Veteran’s reported stressor was related to his fear of hostile military activity and adequate to support the diagnosis of PTSD, considering the complete report of his in-service circumstances. The November 2010 and July 2013 VA examiners determined that the reported stressor was not related to fear of hostile military activity; however, the July 2013 VA examiner did not provide an explanation for that determination, as requested in the examination form. The November 2010 VA examiner determined that it was unlikely that the claimed stressor was related to fear of hostile military activity on the basis that it was not a stressor typically associated with PTSD, without further explanation, and it does not appear that he considered the Veteran’s reports outside of the examination setting of incoming sniper fire. Based on the foregoing, the most probative evidence shows that the Veteran’s testimony is sufficient to establish the in-service stressor occurred. See 38 C.F.R. § 3.304(f)(3). The Veteran’s service treatment records show that he was found to be psychiatrically normal at the time of the March 1968 entrance examination and the January 1970 separation examination, and he denied a history of relevant symptoms on the corresponding reports of medical history. The post-service evidence indicates that he has received an actual or suspected PTSD diagnosis and has reported having symptoms over time that worsened more recently, several years before he filed his claim. See, e.g., historical and current VA treatment records from January 2006 (assessment including PTSD?, started on medication), May 2006 (Veteran reported leaving Vietnam 35 years ago with symptoms over time, becoming worse in the last six years), March 2011 (diagnoses including PTSD), and June 2011 (diagnoses including ?PTSD); July 2011 VA Agent Orange examination report (noted PTSD for 30+ years based on Veteran report of symptoms for that amount of time); October 2020 private evaluation report. In addition, the Board finds that the Veteran has PTSD that is related to the verified in-service stressor. The November 2010 VA examiner determined that the Veteran was not presenting with symptoms of PTSD, and the July 2013 VA examiner determined that the Veteran did not meet the full criteria required for a PTSD diagnosis under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (the edition used at that time). In an August 2013 clarifying medical opinion, another VA examiner only addressed the question of etiology for the separately diagnosed depressive disorder from the 2013 VA examination. The March 2018 VA examiner addressed other psychiatric disorder diagnoses and but does not appear to have considered whether the criteria for a PTSD diagnosis was met. She noted that earlier diagnoses of PTSD assumed the Veteran experienced combat in Vietnam, but she did not consider whether he had such a diagnosis based on his verified stressor. The Board requested a new VA examination and medical opinion because it was unclear if the Veteran had a clinically confirmed PTSD diagnosis. The August 2019 VA examiner determined that the Veteran’s reported stressor was related to his fear of hostile military activity and adequate to support the diagnosis of PTSD, but he did not meet the full criteria required for a PTSD diagnosis under the DSM-5 (Fifth Edition). The examiner explained that it was unlikely that the Veteran had historically ever met the full diagnostic criteria, and that his historical and current symptoms profile most accurately depicted a depressive disorder. The diagnosis was an unspecified depressive disorder that the examiner essentially determined was not related to the Veteran’s military service on the basis that the record indicated that the disorder originated and had been a presence for about the past 15 years (i.e., a post-service onset). The Board notes that the examiner determined that the Veteran did not meet any of the diagnostic criteria for Criteria B through E, which appears inconsistent with his generally consistent presentation documented in VA treatment records and prior examination reports. On the other hand, in an October 2020 private evaluation, Dr. M.C. diagnosed the Veteran with PTSD with dissociative symptoms and delayed expression under the DSM-5 and determined that the disorder was the result of the Veteran’s reported stressor. In so finding, he noted consideration of the Veteran’s in-service circumstances and post-service mental health problems and determined that the Veteran would have also met the criteria for a PTSD diagnosis under the DSM-IV as well. He explained that the Veteran’s symptomatology noted in the record was specific, clear, and focused on trauma-based illness, and the depressive symptomatology was captured in the robust criteria for PTSD, rather than a separate disorder. In addition, Dr. M.C. discussed his observed deficiencies in prior medical opinions as to the question of a PTSD diagnosis and the significance of the Veteran’s historical presentation in this case in reaching the determination as to his current diagnosis. The Board finds that this medical opinion is highly probative, as it is based on a review of the claims file, including an accurate characterization of the evidence, and is supported by rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Based on the foregoing, and resolving any reasonable doubt in favor of the Veteran, the Board concludes that service connection is warranted for PTSD. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Postek, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.